3918 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
PERMIT NUMBER
BUILDING PROJECT IDENTI FICATION APPLICATION & PERMIT 3Q1 O
BUILDING JJ 0
AOORESE
1e =0 . aV120�. NG-ELECTRICAL-PLUMBING-MECHANICAL
OW F '6 PL N CHECK VALIDATION
NAME ff
OTY. ELECTRIC PERMIT FEE
PHONE
CONT AC OR5 ,_`
ry1AM,E 'y I OUTLETS-SWITCHES-RECEP 5.00/1.0 (�f
V l I }j C LIC.NOC-10 ISS LIGHTING FIXTURES 5.00/1.00
i,1, CONTRACTOR'S
P, _ APPLIANCES-RESIDENTIAL 4.00
t � ,a PHONE lj ^ST PANELS 5.00 DATE OF APPLICATION
ARRCHITECT - SIGNS 6.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC.No. SIGNS TRANS. 3.00
ADDRESS ENG, SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
ASMOTORS SEE FEE SCH.
ADDREDDRESSS
SERVICE CHANGE 10.00 �/ � / p
0 0 o LICENSED CON'(RACTORS DECLARATION PAID
/ d}O/O
< Z W I hereby affirm Blot I am licensed under provisions Of Chapter 9 166 ANCE DATE
< u (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLG. MECH.
H w i Professions Co ,and yyy license is in full fppr e'nd ofjLCL� ❑ ❑
11 o i w.Q Licen a C� Iqs;_ '.I_U Co ractorNmnb (-Q�-r -
Date /_-/ _f/(Gq��_'Contractor
a y Cit Of C BUILDING PERMIT
6 0 6 u OWNER-BUILDER DECLARATION INFORMATION
X ; y 1 hereby affirm that I am exempt from the Contractor's License MISC.- REFER TO ORD
F u LL m j Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE VALUATION 6/FT.
Code:Any city or county which mildness permit to construct,alter,
6.00 r,�
2 2 a p improve,demolish,or repair any structure,prior to its issuance,also ELEC,CONTR. LIC.NO. ELED.
O LL requires the applicant for such permit to file a signed statement that TOTAL ?,6.bo
w m he is licensed pursuant to the provisions of the Contractors License y _P��T TO
iii Law(Chapter 9(commencing with Section 7000)ofDivision 3 ofthe LG
4 o Business and Professions Code)or that he is exempt therefrom and CITY. PLUMBING PERMIT FEE
Ie H $ the basis for the alleged exemption.Any violation of5eclion 7031.5 STORIES TYPE CONSTR.
by any applicant fora permit subjects applicant toacivil penalty ALTER-DRAIN -WATER (EA.) 4.00
of not more than five hundred dollars(5500).$500).):
❑ I,as owner of the property,or my employees with wages as BACK FLOW PROTECT. DEVICE 2.00 OCC.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,GOND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SO.FT.FLOOR AREA TOTAL ACREAGE
himself or through his own employees,provided that such improve-
mems are not intended or offered for sale.If,however,the building GAS-EA.SYSTEM-1 INC.4 OUTLETS 4.00
Or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4(EA.) 1.00 BUILDING USE
builder will have the burden of proving that he did not build or im- RES IND CON PB Omor
prove for.purpose of sale.). INDUSTRIAL WASTE INTER. 20.00 11 11 ❑ ❑ El
I,as owner of the properly,am exclusively'contracting with
licensed contractors to construct the project(Sec. 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such project,wid,a contractorls)licensed pursuant to
the Contractor's License Law. SEWER-SANITARY-STORM EA.2001t/8.00 TRACT NO, PARCEL NO.
❑ [am exempt under Sec. ,B,&P.C.for this WATER HEATER W/VENT 4.00
reason
Date Owner WATER SYSTEM 4.00 ACC.DATE ACC,FILE NO.
WORK ERS'COMPENSATION DECI-ARAT ION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure. ZONING ENG.SITE NO.
or a certificate of Workers'Compensation Insurance,
or.a certified
copy therIq[IS; ✓j00,Lab.C.,>. f�UV4N
Policy NO. Ompany r 4x
0 ❑ Certified copy¢hereby famished. FIRESPRINK ENERGY T44
Z 2 N-Certi 'Ip I d wi h h^c' y inspection division. MISC.- REFER TO ORD.
p APPlicum Y❑ N❑ Y ❑ No
,
~ N PERMIT ISSUANCE 6.00 FLOOD ZONE A.L.u.C.
LU CERTIFICATE O' 'XEMPTIFROM WORKERS'
W need not be completed
PLG.CONTR. LIC.NO. PLT, ' Y❑ N❑ Y❑ N❑
IL hundred
dollar,
need not be completed if the perinit is for one TOTAL
U Z hundred dollars(5100)pe less)
LL O I certify , I h the performance of the nark for which this per- OTY. MECHANICAL PERMIT FEE FEE SUMMARY
0 F mit is issued, I shall not employ any person in any manncrs0 jam
U becomesubject to the Wlicant Compensation Laws of California. BUILDING
�•y Date-Applicant - ALTER OR ADD TO MECH. 4.00
} to NOTICE TO APPLICANT: If,after making this Certificate of Ex-
F ? emption,you Should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
CJ such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10.000 C.F.M.) 3.00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 10=C.F.M.) 5.00 SEISMIC FEE
I hereby affirm that there is a construction lending'agency for EXHAUST HOOD (WITH DUCT) 2.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ.C.). HEATING UNIT(TO 100,000 B.T.U.) 4.00
Lender's Name HEATING UNIT ER 100,000 B.T.U.)7.50 �
Lender's Address ELECTRIC
I Certify that I have read this application and State Out the above VENTILATION FAN (SINGLE) 3,00
information is correct. I agree to comply with all city and county PLUMBING
ordinances and state laws refuting to building construction, and BOILER-COMP(3 H.P.Or 100,000 B.T.U.) 4.00
hereby authorize representatives of this city to enter upon theBOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of I MISC.'- REFER TO ORD.
Cupertino against liabilities,judgments, costs a»d expenses which PERMIT ISSUANCE 3.001CONST.TAX -
may in any way accrue
against said City in consequence of the -
gm ling of this pemuL - - MECH.CONT. - LIC.NO. MECH.
D.C7 TOTAL TOTAL
Signature of Apcant/Canlmaar Uue
OFFICE COPY